Pre Need Planning Form

1Contact Information

2Biographical Information

3Funeral Service Detail

Contact Information

Full Name(Required)

First Last

Email Address(Required)

Enter Email Confirm Email

Contact Phone(Required)

Biographical Information For Pre-Need

Full Name

First Middle Maiden Last

Sex / Gender(Required)

Male

Female

Other

Address(Required)

Street Address City State ZIP Code

Military Branch

Date of Birth(Required)

City of Birth(Required)

State of Birth(Required)

Marital Status(Required)

Spouse Full Name

Father's Full Name

Mother's Full Name (Maiden)

Last Occupation

Type of Business

Education Level

Last Grade Completed(Required)

High School Name(Required)

Technical School Name(Required)

College / University Name(Required)

Graduate / Doctorate(Required)

Church Attended

Church Activities

Civic Activities

Funeral Service Details For Pre-Need

Place of Funeral(Required)

Cemetery Name(Required)

Own Gravel Plot(Required)

Yes

Wake Service(Required)

Yes

Preferred Eulogist (To Preach Funeral)

Favorite Songs For Funeral

Persons To Offer Remarks

Type Of Casket Preferred

Vault Preference

Relatives Information For Pre-Need

Closest Relative(Required)

Provide information of the closest relative which will be contacted when the time comes.

First Last

Relationship(Required)

Phone(Required)

Alternate Phone

Address(Required)

Street Address City State ZIP Code

List of Relatives

Provide a list of each surviving relative

Optional Information

My Insurance Policies Are Kept...

My Insurance Agent Is...

Insurance Agent Phone(Required)

My Military Papers Are Kept...

My Grave Deed Is Kept...

I Have Accounts In The Following Banks...

My Attorney / Lawyer or Law Firm Is...

Attorney / Lawyer / Law Firm Phone(Required)

Upload Additional Documents (Optional)

Upload any necessary documents to help with the pre-planning process for future funeral services with Leevy's Funeral Home.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 50 MB, Max. files: 6.